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Case Law: Requests for Medical Must Comply Fully with Rule 16-9 WCRP

On behalf of Eley Law Firm posted in Medical Benefits on Wednesday, May 2, 2012.

Aguirre v. Nortrack, W.C. 4-742-953 (ICAO 3-19-12)

Getting medical benefits authorized is at least half the battle in many workers compensation cases. There are specific procedures that need to be followed in getting authorization for medical treatment. They are covered in Rule 16-9 of the Workers Compensation Rules of Procedure. The rule provides that for many treatments, prior authorization must be requested. Among other things, the request must include a statement of the medical necessity of the treatment or procedure. Once a completed request for prior authorization has been submitted, the insurance carrier has 7 days to respond to the request.

In Mr. Aguirre's case the adjuster did not issue a timely response either allowing or denying spinal cord stimulator requested by his doctor. Mr. Aguirre's attorney set the matte for hearing and asked for penalties under §8-43-304 C.R.S. This is a section of the workers compensation statute that allows for penalties up to $1,000 per day for failure to follow the Colorado Workers Compensation Act, a rule of the Division of Workers Compensation or an order by a judge or the DOWC director. In this case, the alleged violation was that the adjuster had violated the rule not responding to the request for authorization within seven days.

This is where the Claimant's case for penalties fell apart. In his request, the doctor stated that a trial of the stimulator resulted in a 50% reduction in pain and that the Claimant wanted the stimulator. However, the administrative law judge found that the doctor never made a statement as to the medical necessity of the stimulator implant. One would think that a reduction in pain would be enough to show the treatment was needed but the ALJ found that the doctor never explained the medical necessity of the device. The doctor only said that it provided pain relief and that the Mr. Aguirre wanted to go forward with the implantation of the device. Since the request did not include a statement of medical necessity, it was not deemed a completed request for authorization. Therefore, the penalties requested by the Claimant were denied.

The lesson from this case is to make sure that requests for authorizations comply with Rule 16-9. If you are a medical provided, not following the rule completely can delay treatment. If you are a workers compensation attorney and a request for authorization is not acted upon by the adjuster, you should review the request to make sure it's in compliance prior to pursuing judicial remedies. For more on medical benefits, visit the Eley Law Firm website. https://www.eleylawfirm.com/Colorado-Workers-Comp/Medical-Benefits.shtml